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Table of Contents    
LETTER TO EDITOR
Year : 2020  |  Volume : 68  |  Issue : 6  |  Page : 1495-1496

Appearing and Disappearing Ruptured Internal Carotid Artery Bifurcation Aneurysm: Is it Really Fugacious?


Consultant Neurointervention Surgery, Department of Neurosciences, Medanta, The Medicity, Gurgaon, Haryana, India

Date of Web Publication19-Dec-2020

Correspondence Address:
Dr. Gaurav Goel
Department of Neurosciences. Medanta, The Medicity, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.304094

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How to cite this article:
Mahajan A, Goel G, Das B, Narang KS. Appearing and Disappearing Ruptured Internal Carotid Artery Bifurcation Aneurysm: Is it Really Fugacious?. Neurol India 2020;68:1495-6

How to cite this URL:
Mahajan A, Goel G, Das B, Narang KS. Appearing and Disappearing Ruptured Internal Carotid Artery Bifurcation Aneurysm: Is it Really Fugacious?. Neurol India [serial online] 2020 [cited 2021 Jan 27];68:1495-6. Available from: https://www.neurologyindia.com/text.asp?2020/68/6/1495/304094




Sir,

We report a unique case of 25-year-old male who presented with sudden severe headache associated with vomiting for 3 days. Non-contrast computed tomography head was done which showed diffuse acute subarachnoid haemorrhage (SAH). Magnetic resonance angiography (MRA) was performed which showed no evidence of any aneurysm [Figure 1]b. Patient was advised to undergo digital subtraction angiography (DSA), however facility for DSA cerebral vessels was not available in that hospital. Patient was then referred to the center with the facility of DSA and underwent angiography after two weeks. There was evidence of right internal carotid artery (ICA) bifurcation aneurysm projecting anteriorly on right ICA injection [Figure 1]c, [Figure 1]d. He was advised endovascular flow diverter placement however he refused for the treatment because of the financial constraints. After consultation with his family physician, he decided to undergo repeat angiography after 28 days. Cerebral angiography showed significant interval decrease in the size of the right ICA bifurcation aneurysm with residual small aneurysm bleb noted on lateral view of right ICA injection [Figure 2]b. Patient was offered the same endovascular flow diverter treatment for the residual aneurysm bleb. Patient and his attendants were in the view that the aneurysm would spontaneously resolved on its own thus they decided to undergo repeat angiography after two weeks. Patient was presented to us in outpatient department to have second opinion and underwent repeat angiography in our center which showed complete resolution of aneurysm on right ICA injection in a near same projection [Figure 2]c, [Figure 2]d. We did not conclude the angiography to be negative for aneurysm and decided to perform 3-dimensional (3D) rotational angiography (Axiom Artis Zee; Siemens, Erlangen, Germany) and it showed a well visualized residual very small aneurysm less than 1 mm in diameter on posteroanterior and craniocaudal view [Figure 2]e, [Figure 2]f. 2-Dimensional angiography of right ICA was repeated with right oblique caudal projection which revealed very small residual aneurysm [Figure 2]g. In view of persistent significant interval reduction in the size of the aneurysm as compared to previous angiography and financial constraints, patient decided not to go for any procedure that we had advised. Patient was doing well on telephone follow-up after three months. Significant interval decrease in size of the aneurysm in our case was probably due to spontaneous thrombosis. Spontaneous thrombosis of aneurysm on repeat angiography has been well described in the literature.[1],[2] We learned a lesson from our case that we should not conclude angiography to be negative for aneurysm until it is confirmed on 3D angiography. Aneurysm in our case was almost invisible behind the artery near which it arouses on last angiogram which was finally detected on 3D-DSA and 2D-DSA in particular projection. The superiority of 3D-DSA over the 2D-DSA for evaluating the cerebral aneurysm has been reported by many authors.[3],[4] Kawashima et al.[5] also showed that the 3D-DSA tends to show aneurysm bigger than the 2D-DSA especially in anterior circulation. In our case, there was diffuse thick subarachnoid hemorrhage on NCCT head that made high degree of suspicion of occult aneurysm despite the negative first MRA. Thus, patient was advised to undergo repeat angiography after two weeks. Khan et al.[6] also showed in their study that repeat DSA to be done in case of angionegative SAH in the background of high suspicion of occult vascular lesion. We present a unique case of appearing and disappearing aneurysm finding of which can be useful to the literature.
Figure 1: Non-contrast computed tomography (CT) head showed diffuse acute subarachnoid haemorrhage (a). Magnetic resonance angiography, volume rendering coronal image showed no aneurysm (b). 2D angiography was done after 2 weeks which showed an aneurysm in right ICA bifurcation aneurysm (red arrow). Incidental fenestration of right MCA was noted with early origin of temporopolar artery (c and d)

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Figure 2: 2D digital subtraction angiography (2D-DSA) was repeated after 28 days which showed no aneurysm detected on posterior anterior (PA) projection (a) however small aneurysmal bleb (arrow) identified at right ICA bifurcation on lateral projection (b). Repeat angiography was done after 2 weeks, 2D-DSA (PA and lateral projection) showed no evidence of aneurysm (c, d). 3-Dimensional rotational angiography showed a very small aneurysm (arrow) arising from the ICA bifurcation (e, f). 2-Dimensional Angiography right oblique caudal projection showed a very small aneurysmal bleb (g)

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fodstad H, Liliequist B. Spontaneous thrombosis of ruptured intracranial aneurysms during treatment with AMCA. Report of three cases. Acta Neurochir 1979;49:129-44.  Back to cited text no. 1
    
2.
John LD, Atkinson JI, Colbassani HJ, Llewellyn DM. Spontaneous thrombosis of posterior cerebral artery aneurysm with angiographic reappearance. J Neurosurg 1993;79:434-7.  Back to cited text no. 2
    
3.
Hochmuth A, Spetzger U. Comparison of three-dimensional rotational angiography with digital subtraction angiography in the assessment of ruptured cerebral aneurysms. AJNR Am J Neuroradiol 2002;23:1199-205.  Back to cited text no. 3
    
4.
Sugahara T, Korogi Y, Nakashima K, Hamatake S, Honda S, Takahashi M. Comparison of 2D and 3D digital subtraction angiography in evaluation of intracranial aneurysms. AJNR Am J Neuroradiol 2002;23:1545-52.  Back to cited text no. 4
    
5.
Kawashima M, Kitahara T, Soma K, Fujii K. Three-dimensional digital subtraction angiography vs two-dimensional digital subtraction angiography for detection of ruptured intracranial aneurysms: A study of 86 aneurysms. Neurol India 2005;53:287-9.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Khan AA, Smith JD, Kirkman MA, Robertson FJ, Wong K, Dott C, et al. Angiogram negative subarachnoid haemorrhage: Outcomes and the role of repeat angiography. Clin Neurol Neurosurg 2013;115:1470-5.  Back to cited text no. 6
    


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